Dengue Illness

Dengue is a viral infection transmitted by the bite of an infected mosquito. There are four closely related but antigenically different serotypes of the virus that can cause dengue (DEN1, DEN 2, DEN 3, DEN 4).Dengue has a wide spectrum of infection outcome (asymptomatic to symptomatic). Symptomatic illness can vary from undifferentiated fever (viral syndrome), dengue fever (DF), dengue haemorrhagic fever (DHF) and dengue with unusual manifestations. DF and DHF comprise the bulk of symptomatic illness while unusual dengue is a rare entity (usually <1%).

Dengue Fever (DF) – marked by an onset of sudden high fever, severe headache, pain behind the eyes, and pain in muscles and joints. Some may also have a rash and varying degree of bleeding from various parts of the body (including nose, mouth and gums or skin bruising).

Dengue Haemorrhagic Fever (DHF) – is a more severe form, seen only in a small proportion of those infected. DHF is a stereotypic illness characterized by 3 phases; febrile phase with high continuous fever usually lasting for less than 7 days; critical phase (plasma leaking) lasting 1-2 days usually apparent when fever comes down, leading to shock if not detected and treated early; convalescence phase lasting 2-5 days with improvement of appetite, bradycardia (slow heart rate), convalescent rash (white patches in red background), often accompanied by generalized itching (more intense in palms and soles), and diuresis (increase urine output).

Patients should seek medical advice in the presence of following features particularly when fever settles:

Sometimes Dengue patients may present with atypical manifestations like respiratory symptoms such as cough, rhinitis or Injected pharynx and gastro-intestinal symptoms such as constipation, colicky abdominal pain, diarrhoea or vomiting without the classical clinical presentation described above.

If a patient with high fever is seen with flushed face/extremities (diffuse blanching erythema in adults) and a positive tourniquet test (even with a normal platelet count) with leukopenia (WBC <5000 /mm3) without any focus of infection, it is very likely that the patient is having Dengue illness.

In any patient who presents with shock (particularly afebrile at presentation with cold extremities and tachycardia with low volume pulse and hypotension) consider Dengue Shock as a likely diagnosis.

Detection of NS1 antigen from blood is novel laboratory diagnostic test for dengue during early febrile phase. However, NS1 only implies that the person is having dengue illness and it does not help in differentiating DF from DHF. Therefore, NS1 test may be useful in situations where early clinical diagnosis is doubtful.

Value of Full Blood Count (FBC/CBC)OPD level:

FBC is mandatory on all fever patients – from day 3 onwards

Special patient categories – FBC on day 1 or first day of visit/contact (Pregnancy, Infancy, elderly, those with co-morbidities, etc.)

FBC daily from day 3 if platelet (plt) count ≥150,000/ mm3

FBC twice daily when plt count ≤150,000/ mm3 (admission to hospital based on clinical judgment, warning signs and social reasons)

Admit all patients with platelet count ≤100,000/ mm3

Inward level

For any patient admitted to hospital on or before day 3 of illness same criteria of performing FBC as in OPD level is applicable unless and otherwise more frequent counts are requested by the clinician.

Important Advice for Ambulatory Care Patients (OPD level):

First contact doctors should ensure adequate oral fluid intake.

In adults around 2500 ml for 24 hours (if the body weight is less than 50kg fluids given as 50ml/kg for 24hours or 2ml/kg/hr) is recommended during Febrile Phase (before admission to hospital).

In children calculation of maintenance fluid is as follows:

M (Maintenance)=100ml/kg for first 10 kg +50ml/kg for next 10 kg +20ml/kg for balance weight

Patients/parents should be asked to return immediately for review if any of the following occur on/beyond day three:

Clinical deterioration with settling of fever

Inability to tolerate oral fluid

Severe abdominal pain

Cold and clammy extremities

Lethargy or irritability/restlessness

Bleeding tendency including inter-menstrual bleeding or menorrhagia

Not passing urine for more than 6 hours

Differentiation of DHF from DF:It is important to differentiate DHF from DF early because it is the patients with DHF who develop plasma leakage and resultant complications usually after the third day of fever. DHF may become evident as the fever settles. Tachycardia (increase heart rate) without fever (or disproportionate tachycardia with fever) and narrowing of pulse pressure (eg: difference between systolic and diastolic narrows from 40mmHg to 30 mmHg) is an early indication of leaking which warrants referral to the hospital. A progressively rising Haematocrit suggests that the patient may have entered the leaking phase. However, an ultra sound scan focused on chest and abdomen to detect selective and progressive fluid accumulation is a more objective evidence of plasma leakage in DHF.

Admission to a hospital:The first contact doctor will decide to admit a patient to a hospital based on the clinical judgment. It is essential to admit the following patients:-Platelet count below<100,000/mm3 -With the following warning signs on or beyond day 3 of fever/illness: